©September 2008

Many communities around the United States engage in an annual ritual called a “Health Fair.”  While such events are organized as differently as the communities themselves, they often make certain screening tests available to participants and arrange for counselors to help people make some sense of our so-called “health care system.”  However, one service that is not usually provided at Health Fairs is a physical examination, or “P.E.”  Therefore, it might be worth pondering the value of a physical exam, and taking a moment to consider its place in the preventive services armamentarium.

The United States Preventive Services Task Force (USPSTF) is assigned the task of identifying those preventive services which are recommended for the general public.  Several criteria are used to assess various preventive procedures to see if they make sense.  Such criteria include the prevalence of the illness to be prevented, the effectiveness of the detection method, the disability caused by a preventable condition, the effectiveness of disease treatment once it (or the risk of it) is detected, possible negative consequences of a preventive intervention, and finally the cost of a preventive procedure, test or treatment.  All of these criteria must be used to determine if a particular preventative step should be recommended to the public.

A physical examination requires that the patient bring his/her body to the care givers office.  It also requires that the patient’s body be looked at, touched, moved, probed and scrutinized with fairly primitive lights and lenses.  To do so requires that the patient remove his/her clothing.  Otherwise, a P.E. might be accomplished simply by sending ones laundry and a photograph to the care givers office.  Make a note of this when you are next seen for a routine physical examination.

It is now becoming popular, particularly in rural areas with limited availability of certain specialty physicians, for certain clinics to be conducted via camera, through something called “telemedicine.”  The patient is observed through a video camera and the specialist is also visible on a monitor while the patient is interviewed and visually evaluated.  Psychiatry and Dermatology are specialties for which this system sometimes works fairly well.  However, “telemedicine” is not a satisfactory method of performing a routine P.E.

While asymptomatic discoveries during a P.E. are unusual, they do indeed occur.  Whether it is a new heart murmur, an enlarged liver, a new spot on the skin or a lump that was previously undetected, with enough time in practice virtually every doctor has encountered such instances.  While it is fairly uncommon for these findings to be life saving, it is not rare that these unexpected results enhance the quality of life of the patient.  At the very least, such instances remind the patient that they are connected to the human race.  These are examples of some of the benefits of a regular physical examination.

However, one of the less celebrated benefits of a P.E. is difficult to encapsulate and even more difficult to measure.  This is the moment within the examination room when personal, confidential concerns and troubles that are encountered in every day life are shared.  These generally are items that affect our health, but sometimes include things that we may not even recognize as health concerns.  The treatments provided by the care giver may be nothing more than lending an ear, or answering questions tuned to the individual life of the patient.  However it is this moment during the exam when issues affecting the quality of life can be addressed and reflected.  It is an opportunity that the care giver recognizes as the greatest privilege of his/her profession, and it is an opportunity for the patient that should not be squandered.

The goal of a physical examination will be different, depending upon the age and/or developmental stage of the patient. During infancy, a P.E., traditionally called a “well-child exam,” is focused upon the developmental milestones, immunizations and parental education.  A physical examination during the prepubescent years will raise new questions about relationships and body changes that may have the young persons head spinning.  Young adulthood will touch on many issues that are forming lifelong objectives for the patient.  More than 50% of adult patients will have complaints that revolve around happiness and satisfaction with their lives.  And older patients often teach providers what to tell all the others.

While specific recommendations for a P.E. are not generally agreed upon by all specialty organizations, the following represents a recommended approximate frequency for routine physical exams for the general population based upon the current guidelines of the USPSTF and the California Child Health and Disability Prevention program (CHDP). You should consult your private care giver to determine the frequency of physical examination for your specific needs:

Infancy:  At birth, age 2 weeks, 2 months, 4 months, 6 months, (9months), 12 months, 15 months, 18 months, 2 years

Childhood: At age 3 years, 4-5 years, 6-8 years, 9-12 years, 13-16 years, and 17-20 years

Adult: Every three years between 20-39 years of age

           Every one to three years between 40-64 years of age

Senior: Every year from age 65 and older

December 20, 2017

When I read the recent headline that our nation’s primary public health agency, the Centers for Disease Control and Prevention (CDC), has been “prohibited” from “using seven words in official documents used for next year’s budget,” I found myself stomping around the house in disbelief.

As clarified by the CDC director, the truth of this news is probably less provocative than the face value of that headline.  And yet, the preponderance of evidence points to an ongoing and relentless effort to undermine science and scientific principles by our political leaders.  The proverbial last straw has landed on this camel’s back.

In 1996, a federal budget bill stated that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

Subsequently, Congress eliminated funding for Gun Violence Prevention Research at the CDC.  Funding declined from $2.6 million in 1996 to zero in 2014, 2015, 2016 and 2017, despite a request for $10 million for each of those four years.

This lack of funding prevented scientific research that may have helped address firearm violence in this country, like a 2009 study of suicide rates in California that was funded by local Tuolumne County dollars to identify that, over the prior decade, for every firearm-related homicide in rural parts of the state, there were approximately four firearm-related suicides.

A disrespect for science can cause politicians to blunder into the realm of pseudo-science in response to public outcry, designing legislation with good intentions but with disastrous results.

In 2001, AB 487 was approved by Governor Davis requiring physicians in California to receive 12 hours of training in pain management because of a perception “that physicians consistently fail to manage their patient’s pain appropriately” in part due to “…undertreatment and undermedication.”

The passage of this bill coincided with the release of new opiate medications by pharmaceutical companies.  The encouragement to prescribe long-acting narcotics provided by AB 487 in conjunction with savvy marketing by pharmaceutical companies helped pave the way to today’s opiate addiction crisis.

Pseudo-science and ideological convictions may even misguide us to oppose sound science.  The trail of scientific discovery is littered with the lives of scientists whose sacrifices have resulted in the eradication of smallpox, travel into space, the control of yellow fever and endless research that has either proven or disproven contemporary theories.

To ignore the practical benefits of new discoveries discounts the sacrifices of these modern explorers.  If such neglect aggravates global climate change or results in a chronically ill child contracting an unnecessary infectious disease in school, it is nothing short of tragic.

Scientists must also bear some of the blame for public skepticism.  Real science is humble.  While scientists are generally superb at describing their fields of expertise, they are often not so good at translating their knowledge to the masses.  Science has unfortunately abdicated marketing to the corporate world that stands to prosper from the sales of products and services that are the fruits of science.

Here in Tuolumne County we are trying to change that.  A program called the Exploratorium of Health Care Careers will visit every public school in the county this year.  It is also active in Calaveras County and will be starting in Merced County this spring.

The program is made possible by an intrepid group of volunteers from many scientific and educational backgrounds who are seeking to introduce local 7th, 8th and 9th graders to the wonders and rewards of careers in science and health care.

But to bring new generations into those fields we must encourage students to ask questions.  They must shed their fear of asking the “wrong” question.  We cannot do that if our leaders prohibit our best scientists from asking certain questions or “using seven words” – or for that matter even one word – in their quest to understand our world better and to improve our lives for tomorrow.

If we accept this kind of scientific censorship we degrade the quality and integrity of our science and lower the expectations of tomorrow’s scientists.

In today’s world, with all its diversity, we need to instill our youth with evidence-based and science-based reasoning, so that tomorrow all of us – from the vulnerable fetus to the transgender community – can benefit from opportunities that represent our entitlement.

©December 2007

It is not necessary to have mechanical expertise in order to know that different models of cars are known for certain strengths and weaknesses.  Volkswagen transmissions are famous for being nearly indestructible, but their electrical systems have a reputation for leaving one in the dark.  Certain SUVs have had a nasty habit of tipping over, while some trucks are reportedly stout enough to haul a brontosaurus.  Some engines require an oil change every 3,000 miles, while others may go 8,000 or more.  In fact, if you have ever listened to the “Car Talk” radio show, it is astonishing how the skills that are desirable to find in an automotive mechanic are identical to the skills one would like to find in one’s personal physician.  Perhaps the most artful component of both professions is the ability to identify those maladies to which one is particularly susceptible, and to provide a little preventive care before one finds oneself at the side of the road calling a tow truck.

Screening for cancer follows this principle exactly.  When we are born we are dealt a hand of cards made up of approximately 30,000 genes.  Each of these genes describe our hereditary characteristics, including our strengths and our susceptibilities to various illnesses and cancers.  Some families have higher risks of breast cancer, some higher risks of colon cancer, some leukemia (cancer of the white blood cells) etc…  In fact, with the recent surge in our understanding of human genetics, it is conceivable that in the future there will be a panel of blood tests through which health care providers will be able to predict which cancers and health conditions pose the greatest threat to individual patients.  It may be that the schedule of recommendations for preventive health care – mammograms, cholesterol levels, blood tests for prostate cancer, special X-rays studies, etc… – will be personalized to each individual to provide the greatest benefit for the least expense.

But, of course, this only represents part of the story.  While genes can predict certain risks we face, how we live our lives has an enormous impact on whether those potential risks become reality.  To go back to our automobile metaphor, you may have a very dependable car, but if you drive it like a maniac you can bet that your brakes are not going to last and your engine life will fall short of expectations.  Similarly, a smoker is exposing lung cells to an irritant which is encouraging cells to constantly heal, or reproduce.  Over time, the particular lung cells that are best equipped to confront the challenge of tobacco smoke are those cells which are reproducing most rapidly.  This environmental pressure is all that is needed to encourage a genetic weakness for cancer to surface.  After all, cancer is simply a cell which has forgotten to do it’s job, and instead devotes all of it’s energy to reproduction.  If the cards contain a susceptibility to allowing cells to behave in this way, cancer is the result of constant exposure to tobacco smoke.

It is the job of a health care provider to advise patients to undergo certain tests based upon their hereditary risks and personal behaviors.  Standard recommendations for preventive health care are based upon the frequency of certain health conditions in the entire population.  The United States Preventive Services Task Force (USPSTF) is the group assigned with the responsibility of developing these standard recommendations to prevent cancers from developing and to catch them at a stage during which cancers can be cured.  In order to make such recommendations, the costs of screening tests  – both monetary costs and physical costs – are taken into account.  In addition, the USPSTF considers other factors before making recommendations, such as the accuracy of any given test, and the ability to alter the course of a given illness after a test result is abnormal.  You can look up these recommendations at www.ahrq.gov/clinic/uspstfix.htm

While we do not come with a factory warranty, there are steps that can be taken to extend our individual mileage.  It is worthwhile to consider the risks that are inherent in our families and to discuss preventive health care recommendations with our personal health care providers in order to maximize our ability to enjoy the ride.

©September 2008

The United States Preventive Services Task Force is assigned the task of identifying those preventive services which are recommended for the general public.  Several criteria are used to assess various preventive procedures to see if they make sense.  Such criteria include the prevalence of the illness to be prevented, the effectiveness of the detection method, the disability caused by a preventable condition, the effectiveness of disease treatment once it (or the risk of it) is detected, possible negative consequences of a preventive intervention, and finally the cost of a preventive procedure, test or treatment.

First, the public health literature is analyzed to find those health conditions which cause the greatest harm to the population.  Relevant factors include whether a condition is common, whether it leads to considerable disability, and whether it frequently leads to negative consequences or a fatal outcome if not detected.

Secondly, preventive measures to prevent associated illness are assessed to see if they are effective, accessible and safe in preventing the illness.  Immunizations, for instance, are carefully screened before they are licensed to the pharmaceutical companies to determine if they are effective in preventing the various vaccine preventable illnesses, affordable and relatively free of side effects.

Similarly, if effective treatment for the condition is not readily available, then early detection is less likely to demonstrate a benefit.   Small cell carcinoma of the lung continues to have a relatively poor prognosis, even when detected early by a chest X-ray.  This partly explains the reason why routine chest X-rays are not an effective screening test for the general population, although they may be worth considering for certain smokers.

The potential NEGATIVE effects of preventive procedures are also examined by the USPSTF to determine which tests should be recommended.  A chest X-ray does involve exposure to radiation in the form of X-rays, and this is another reason why an X-ray or CT scan is not an ideal screening test.  Also, vaccinations are carefully reviewed for safety before they are widely recommended.  Sometimes new concerns are raised about a particular vaccination after they are widely distributed to millions of people.  The newly identified risk must then be compared again to the effectiveness of the vaccine, but such an assessment should take into consideration the benefits that have already been achieved by a particular vaccine.  It was for this reason that vaccination recommendations changed after polio in the U.S. became so rare that the live oral vaccine was considered less safe than the inactivated injectable vaccine.  Therefore, a switch to the injectable vaccine was recommended.

Some tests have a high false positive rate, meaning that they incorrectly raise the possibility of the presence of an illness when in fact no illness is actually present.  If further investigation for the presence of disease is possibly dangerous, like an abdominal surgery in a patient with an elevated CA-125 blood test for ovarian cancer screening, then this risk must also be considered before suggesting the test in the first place.

Healthy debate about whether or not to participate in screening tests at Health Fairs and through programs that are offered by health systems is part of conscientious personal care.  Unfortunately, there are self-serving programs out there selling screening services for profit rather than for a benevolent interest in improving your health.  To sort through the bewildering array of solicitations that most people receive trying to sell you a preventive service, like bodily CT scans and ultrasounds for otherwise healthy individuals, your personal health care provider is your most valuable resource.  In addition, the USPSTF recommendations are easily accessed with an internet search.

©February 2008

Public health experts often spend their waking hours contemplating disease prevention in terms of primary, secondary and tertiary prevention.  “Primary prevention” represents steps that can be taken by the general public to prevent a disease from occurring in the first place in an otherwise healthy person.  In heart disease, avoidance of smoking and controlling cholesterol levels by eating a healthy diet are examples of primary prevention.  “Secondary prevention” involves recognizing individuals who have an increased risk of disease and intervening to lower that risk.  After discovering an elevated cholesterol level on a screening blood test, instituting weight loss and/or treating the condition by taking a cholesterol-lowing medication would be considered “secondary prevention.”  Finally, “tertiary prevention” is the process by which a person who has already contracted an illness can take steps to prevent the disease from becoming worse.  Thus, a person who has already suffered a heart attack can undergo a cardiac catheterization and have a blocked artery reopened with a balloon and/or a tiny flexible tube called a “stent” can be placed to keep the artery open.  This would be a tertiary prevention for this person’s heart disease problem.  Recognizing February as American Heart Month gives us an opportunity to discuss a very important type of “tertiary prevention” that can be utilized by every person to improve the outcome of heart attacks in the general population: learn Cardiopulmonary Resuscitation (CPR).

First, a reminder about the important principles of CPR.  In 2010, the American Heart Association changed recommendations to reflect the importance of cardiac compressions in CPR.  Instead of the previous recommendation (A=Airway, B=breathing, C=cardiac compressions), the new protocol calls for starting with “C” (“circulation,” and “cardiac” or “chest” compressions), and THEN addressing “A” (airway and air movement), and finally “B” (breathing for the patient if air is not moving).  When you witness a person who collapses in front of you, if the person does not respond or move in response to your brief check, call 911 or send someone to call 911 and see if there is an Automatic External Defibrillator (AED) in the vicinity.  An AED device will usually be labeled in a box mounted on the wall, often with a first aid sign or a red cross.

Then check for a pulse or cardiac activity (Circulation).  If no pulse within 10 seconds of feeling, begin chest compressions at a rate of 100 compressions per minute.  For lay rescuers, only hands-on CPR without administering breaths is recommended.  These 2010 recommendations changed from previous protocols because too many rescuers were delaying chest compressions to administer breaths.

If a trained individual is administering CPR and chest compressions have already been instituted, attention to the airway and breathing (Airway and Breathing) follows, depending upon the training of the professional and the equipment that is available.  If the person was eating at the time or collapse or showed evidence of choking prior to collapse, remember to consider that a juicy bite of steak just might be the culprit.  In this case, you may need to administer an abdominal thrust, also known as a Heimlich maneuver.

The chance of survival for a victim of sudden cardiac arrest can be doubled by the quick institution of CPR.  According to 2017 Heart Disease and Stroke Statistics, only 40 to 50% of victims of out f hospital cardiac arrest receive CPR.  Given that the time interval for EMS arrival is often 7 to 8 minutes or longer and that survival falls 7% to 10% for each minute without CPR, the lack of bystander CPR has a large impact on outcomes.

If given a choice, public health officials will always choose primary prevention over tertiary prevention, since prevention of disease in the first place is always a better deal.  However, no good communitywide plan is complete without having a way to help victims of illness, including victims of heart attacks.  One of the best gifts you can give your community may be to train yourself in the administration of CPR.  As you go about your day today, consider that any one of the people you meet could be either a person whose life you might save, or perhaps they may be your rescuer.

©July 2012

At first glance, “preventive health care” appears to refer to things that prevent us from getting health care, like when the nearest participating provider for your insurance plan practices in Albuquerque. In fact, preventive health care refers to steps a person can take to increase wellness and prevent illness. Examples are vaccinations, mammograms and colonoscopies, which a group of experts who know nothing about our personal lives recommends be performed on a specific schedule.

If these experts did know about our personal lives, they would know that competition for our time between these preventive health activities and virtually anything else – including playing Wiffle Ball barefoot in a field of star thistle – is no contest.

The committee of experts is the United States Preventive Services Task Force (USPSTF). It has the unenviable job of scrutinizing scientific research and weighing the risks and benefits of a long list of tests and treatments, then drafting recommendations which will make our lives longer and, presumably, more pleasant.

While it may sometimes appear like a game of Simon Says, these recommendations are the product of tedious scientific analysis and debate about collective values, social equity and cost. That they are regularly modified and updated is tribute to the humility of science in the face of new discoveries and the dynamic nature of the effort to improve our lives within a practical budget.

Their key preventive health recommendations – including colon cancer screening, mammography and regular physicals – just might successfully compete with Wiffle Ball-on-thistle for your time.

Colon cancer screening

There are two suggested tests for colon cancer, the second leading cause of U.S. cancer deaths after lung cancer (for which there is no recommended screening for the general population). A stool test can detect any blood that might be oozing from a small growth, a “polyp,” that can grow inside the colon.

About 3 percent of polyps larger than one centimeter in diameter will become cancerous each year.  The key here is to remove the polyp before it becomes cancerous.

If blood leaks slowly from a polyp, it is not typically visible to the naked eye, so a chemical test of multiple stools on a card is usually required. Side note: It is still always a good idea to “look before you flush,” since a bowel movement, even if not as sensational as a supermarket tabloid, can provide some pretty good clues about our health.

The second test, a colonoscopy, uses a fiber-optic scope to detect polyps within the entire five-foot length of the colon. Polyps can often also be removed and biopsied during the procedure.

Persons of average risk should get this test at age 50, earlier for those with higher risk. Risk factors include a close family history of colon cancer, inflammatory bowel conditions, African-American ethnicity, obesity and smoking.

Breast cancer screening

A mammogram – a low-dose X-ray of the breasts – can locate abnormal growths while treatment is still likely to be successful. Breast cancer is the most common invasive cancer in females and is the second most common cause of cancer-related death in women. The discomforts of mammography are legendary and are a genuine source of empathy from the male gender, particularly when wince-worthy anatomical parallels are envisioned. However, considerable work has gone into minimizing the distress of the exam and, reportedly, the discomforts are much less than in past years.

Women with an average risk of breast cancer should have a mammogram every other year starting at age 50. Tests can begin before 50 if warranted by special risks – family history, smoking, medication and other scientific factors – or the patient’s personal values.

Art of medicine

Herein dwells the art of medicine.

It should be noted that none of the adversarial health conditions that we face throughout our lives are strictly linked to the exact number of birthday candles on our cakes. Nothing magic happens after age 40, 50 or 60, despite the fact that many of us are convinced that corrective lenses became necessary as we slept overnight on our 40th birthday.

Still, we cling stubbornly to a quantum theory of aging, worrying instinctively about age thresholds in groups of 5 or 10 years. Thus, while the USPSTF recommendations are standardized by extensive research, they also leave room for adjustment according to individual risk. Therefore, some providers may recommend a mammogram at age 50 for one patient and at age 44 for another.

It is also worth noting that part of risk assessment includes the impact of screening tests upon the convictions of the patient. Some patients feel better and in fact their health may improve after undergoing tests that confirm there’s no underlying disease or illness. This may enter into a doctor’s decision to order a test early.

Prostate debate

Prostate cancer screening in males has many issues in common with breast cancer screening in females.  The routine screening of average-risk older males with the Prostate Specific Antigen (PSA) test remains controversial. The USPSTF recently came out with a recommendation against routine testing of the blood for PSA to detect otherwise undetectable prostate cancer in average risk men, but the committee also highlights that the decision to undergo PSA testing should include a careful consideration of health and lifestyle risk factors, personal values and should definitely include advice from one’s health care professional.  It is important to obtain this advice before testing for PSA, since making a decision after the test results are in your hand means that you are already partly down the road of the assessment.  The decision whether to embark on testing in the first place is easier than turning around and going back.

Routine physicals

How often should we have a routine physical exam even though we feel just fine?  The USPSTF no longer provides a specific schedule, but the following standards generally apply – with a nod here to grandparents who may be responsible for their grandchildren’s health care.

During the first year of life, pediatric visits are scheduled frequently, with five visits during the first two years, coinciding with childhood vaccinations. Between 2 and 6 years, well-child visits are scheduled at least two to four times to monitor development and prepare for school. Between ages 7 and 12, at least one pre-adolescent visit should be done. One or two visits are very important between 13 and 18 years to contend with teenage turmoil, hormones, and vaccinations.

From age 19 to 40 or so, visits can be made every one to three years, depending on risk factors and your doctor’s discretion. Regular physical examinations should start for average-risk women at age 19 (earlier if sexually active), and Pap tests (a test of the woman’s cervix to screen for risk of cancer) at 21, and then repeated every 3 years until about age 65.

Just as tune-ups are important for your car after the odometer clicks past 250,000 miles, between 40 and 45 it is a good idea to increase the frequency of clinic visits in order to plan a schedule for periodic tests that screen for specific conditions like colon and breast cancer. At these clinic visits, the clinician will look over risk factors like family history, smoking history, occupation, medications and demographics in order to decide when to begin the special tests that were mentioned earlier or whether tests like mammography and colonoscopy can wait until after age 50.  Someday, there may well be a battery of genetic tests that will be done in the decade between age 40 and 50 that will help plan a patient-specific schedule for such tests, but this day remains over the horizon.  For now, an increased frequency of physical examinations during this decade of life serves the purpose.  And do not forget that a “physical examination” requires the clinician to employ the senses of sight, hearing, touch and even smell to fully perform such an examination, the sense of taste having been replaced by laboratory testing.

Most doctors recommend physical examinations every year after age 50. After age 90, your doctor may encourage regular visits if only to gain advice from you.

Daily decisions

Another preventive practice is perhaps even more important than tests and treatments. This kind of care happens when we choose a salad instead of a Value Meal, drink a glass of water rather than a sugar-saturated soda, or walk to an appointment instead of driving.

We spend only about .02 percent of our lives with our doctors and health care providers. The other 99.98 percent of the time we are with our families, in our homes, preparing meals, meeting friends, going to work, raising kids, hunter-gathering and shopping.

The only healthcare provider available at these times is you, and your decisions are limited only by the choices available in your community. Recent research suggests that where we live may have more influence on our health than heredity or access to a caregiver. There’s a new push for communities to make healthy choices easier: encouraging access to stores selling seasonal fruits and vegetables, teaching skepticism about advertising claims, and designing residential areas with walkable access to amenities, schools and commercial areas. Preventive health care really gains traction in the unfolding of the daily routine of our lives.

Rx: Inspiration

People who have followed the rules throughout their lives by not smoking, by maintaining a good weight and by feeling good about themselves and their partners will on average be much better off when they enter the silver years than those seniors who have travelled rough and stormy roads.  Those who have problems like high blood pressure and excessive weight gain during their lives can  take preventive steps such as using medication, changing their diet and exercising more to prevent these conditions from worsening.

Of course, every person will eventually experience some kind of serious illness, and when this occurs treatment will include measures such as coronary bypass surgery or chemotherapy to reduce the consequences of further illness.

While we all face these inevitable risks in exchange for the privilege of waking up each morning, reminding ourselves of the rewards as well as the risks is worthwhile. Enjoying each day to the extent that we can is as effective a preventive measure as any. After all, every good laugh surely adds to the inspiration required to see to it that our personal machinery is well-maintained.

©July 2008

Disease prevention is a familiar battle cry of public health.  It is better to diminish the risk of disease before an assault begins than to wait for the first skirmishes to occur.  But there are several criteria that must be met for a particular test to effectively identify risk of illness, and thereby allow an opportunity to prevent disease.  Colon and rectal (“colorectal”) cancer prevention provides an excellent opportunity to explore the characteristics of screening tests that can make a difference.

The tests recommended for colorectal cancer prevention fall into two categories.  The “fecal tests” involve testing the bowel movements each year by collecting small smears of stool on a card or in a container.  There are several “fecal occult blood tests” (FOBT) available for this which test for the presence of otherwise invisible amounts of blood in the stool.  Each should be done carefully and in accordance with recommendations provided with the test.  There are also new fecal tests available that detect certain cancer markers in the stool, but these are more expensive.

The second category of testing includes examinations of the structure of the lower bowel (the colon) and rectum, most often with a scope called a colonoscope or sigmoidoscope.  Fourteen million annual colonoscopies are performed in this country.

Each person’s health care provider will recommend the test that is most appropriate for the individual based upon factors like family history, age and overall health.  In general and in accordance with American Cancer Society recommendations, colorectal cancer screening should begin at age 50 years.

For a preventive test to be effective, the disease you wish to prevent must be worthy of attention.  It makes little sense to mount a campaign to identify people at risk of developing hiccups.  Colorectal cancer is the second leading cause of cancer death and the third most common cancer in the United States, more than justifying the effort to screen for the disease.

Even though no test is perfect, a test that is used to screen the population for risk of disease must be acceptably accurate, without over-measurement or under-measurement.  In the case of colorectal cancer, the target being measured may be blood in the bowel movement, DNA in the bowel movement or physical abnormalities in the lining of the colon or rectum, called “polyps” (small lumps attached to the lining) or “ulcers” (shallow sores).

Even if the test is accurate, it must be capable of detecting disease risk at a time when steps can be taken to cure the patient.  In some cases, a colorectal cancer test may detect polyps or growths before they are cancerous, and in other cases they may detect growths that have already turned cancerous.  To be effective, a colorectal cancer test must detect cancers or pre-cancers at a time when surgical treatment of the condition, either via a scope or by traditional surgery, is curative.

The test must be affordable.  In an era when “affordable health care” sounds ever more like an oxymoron, there is little need to explain why affordability is a vital part of any health care recommendation.  Screening tests for colorectal cancer may be completely free, such as Fecal Occult Blood Testing at the annual Tuolumne County Health Fair, or screening may run up to as much as $6000 for a colonoscopy and biopsy.  An affordable method of screening should be available for every person, and ultimately saves in health care costs to the community.

Finally, people must be willing to undertake the test.  It is difficult to motivate the public to perform tests on three separate bowel movements when they prefer to deny any personal relationship to sewage whatsoever.  However, people become increasingly compliant with annual stool tests, colonoscopy or other screening modalities as they learn the value of colorectal cancer screening and hear of friends or relatives who have benefited from early detection.

Screening rates for risk of colorectal cancer by low income households in our area steadily decreased between 2001 and 2005, while colorectal cancer screening for the general population increased by almost 10%.  These kinds of trends contribute to the disparity in health between different economic segments of our community.  At least in regards to colorectal cancer prevention, screening tests are available that are effective and affordable.  Please spread the word that this simple test is worth your time: fecal occult blood tests will be available at the Tuolumne County Health Fair in October.